Healthcare Provider Details

I. General information

NPI: 1801855440
Provider Name (Legal Business Name): SHANNON D CAMPBELL ATC/L
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 9TH AVE
LEWISTON ID
83501-2659
US

IV. Provider business mailing address

330 N GRANT ST
MOSCOW ID
83843-3674
US

V. Phone/Fax

Practice location:
  • Phone: 208-748-3102
  • Fax:
Mailing address:
  • Phone: 208-882-3239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-067
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: